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Best of HCV from EASL 2015

Expert Perspectives: Best of HCV from EASL 2015 Graham Foster, MD, PhD Cihan Yurdaydin, MD

This activity is supported by educational grants from AbbVie, Bristol-Myers Squibb, and Gilead Sciences.

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Grazoprevir (GZR; MK-5172) + Elbasvir (EBR; MK-8742) Future Treatment Option

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New Fixed Dose Combination: GZR/EBR

•  HCV NS3/4A inhibitor •  100 mg once daily, oral

Grazoprevir (MK-5172)

Elbasvir (MK-8742)

•  HCV NS5A inhibitor •  50 mg once daily, oral

•  Broad in vitro activity against most HCV genotypes 1-3 •  Retains in vitro activity against many clinically relevant RAVs1-3

1.  Summa V, et al. Antimicrobial Agent Chemother 2012:56;4161-67 2.  Coburn CA, et al. ChemMedChem 2013; 8: 1930–40 3.  Harper S, et al. ACS Med Chem Lett. 2012 Mar 2;3(4):332-6.

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The Phase 3 C-EDGE Treatment-Naïve Study of a 12-Week Oral Regimen of Grazoprevir (GZR; MK-5172)/Elbasvir

(EBR; MK-8742) in Patients With Chronic HCV GT 1, 4 or 6 Infection

S. Zeuzem et al

Abstract G07

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SVR 12: Full Analysis Set

Non-virologic failure 4 3 1 0 0

Breakthrough 1 1 0 0 0

Relapse 12 9 1 0 2

Zeuzem et al., Abstract #G07, EASL 2015

95% 92% 99% 100% 80%

0 20 40 60 80

100

All Patients

GT 1a GT 1b GT 4 GT 6

Patie

nts,

(%)

299/ 316

144/ 157

129/ 131

18/ 18

8/ 10

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C-SALVAGE: Grazoprevir (GZR; MK-5172), Elbasvir (EBR; MK-8742) and Ribavirin

(RBV) for Chronic HCV-Genotype 1 Infection After Failure of Direct Acting Antiviral

(DAA) Therapy

X. Forns et al

Abstract O001

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GZR + EBR + RBV x 12 Weeks: SVR12 By Subgroup

All Subjects N = 79

SVR12 76 (96.2%) Relapse 3 (3.8%) By Prior PI Therapy

Boceprevir 27/28 (96%) Telaprevir 41/43 (95%) Simeprevir 8/8 (100%)

By Prior Failure Category On treatment failure 38/40 (95%) Relapse 25/26 (96%) Intolerance 13/13 (100%)

By Time Since Therapy <1.1 year 22/24 (92%) ≥1.1 year 46/46 (100%)

By Presence of NS3 RAVs

Absent 43/43 (100%) Present 31/34 (91%)

All Subjects N = 79

SVR12 76 (96.2%) By Genotype

G1a 28/30 (93%) G1b 48/49 (98%)

By Cirrhosis Yes 32/34 (94%) No 44/45 (98%)

By Viral Load ≤800,000 IU/mL 27/29 (93%) >800,000 IU/mL 49/50 (98%)

• Highly efficacious in patients who failed first generation protease inhibitor/PEG/RBV treatment

Forns et al., Abstract #O001, EASL 2015

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Advanced Chronic Kidney Disease Review of New Data

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Safety of Ombitasvir/Paritaprevir/Ritonavir Plus Dasabuvir for Treating HCV GT 1 Infection in Patients With Severe Renal

Impairment or End-Stage Renal Disease: The RUBY-1 Study

P. Pockros et al

Abstract L-01

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Background/Objectives

• 12 weeks of OBV/PTV/r + DSV – GT 1 treatment-naïve

•  Included RBV for GT 1a

•  No RBV for GT 1b

– CKD stage 4/5, including 60% on hemodialysis

– Excluded cirrhotics

Pockros, et al. Abstract #LP-01, EASL 2015

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Summary

• Regimen has been well tolerated, including those on hemodialysis, with or without RBV

• Hemoglobin reductions were managed with monitoring and RBV dose interruption (8/13) and erythropoietin use (4/13)

• No virologic failures to date and all 10 subjects who reached PTW4

Pockros, et al. Abstract #LP-01, EASL 2015

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C-SURFER: Grazoprevir Plus Elbasvir in Treatment-naïve and Treatment-experienced

Patients With HCV GT 1 Infection and Chronic Kidney Disease

D. Roth et al

Abstract LP-02

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Background/Objectives

•  <1% of GZR and EBR is renally excreted

•  This study evaluated GZR+EBR in HCV-infected patients with CrCl<30 mL/min, including patients on hemodialysis

– GT 1 treatment-naïve or treatment-experienced

– CKD stage 4/5

–  Included compensated cirrhotics

Roth, et al. Abstract #LP-02, EASL 2015

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SVR12: GZR/EBR for 12 Weeks in GT1 Patients With Chronic Kidney Disease

•  GZR/EBR was generally safe and well tolerated.

aNoncirrhotic, interferon-intolerant patient with HCV GT1b infection relapsed at FW12. bLost to follow-up (n = 2), n = 1 each for death, noncompliance, withdrawal by subject, and withdrawal by physician (owing to violent behavior).

Relapse 1a 1

Discontinued unrelated to treatment

0 6b

99 94

0

20

40

60

80

100

Modified Full Analysis Set 16 Weeks

Full Analysis Set 24 Weeks

Patie

nts,

%

115/116 115/122

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How Do We Currently Manage HCV-infected Patients With CKD Stage 4/5?

Are We Concerned With Using RBV For

GT 1a Patients?

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Can We Simplify the AbbVie Regimen for GT 1b?

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Ombitasvir/Paritaprevir/Ritonavir for Treatment of HCV Genotype 1B in Japanese Patients With or

Without Cirrhosis: Results from GIFT-1

K Chayama et al

Abstract G13

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Background/Patient Population

•  2 DAA regimen: ombitasvir/paritaprevir/ritonavir

– No interferon, ribavirin or dasabuvir

– 12 week treatment

• Patient population

– GT 1b-infected Japanese patients

–  Included cirrhotics

– Treatment naïve or IFN-experienced patients

Chayama et al., Abstract #G13, EASL 2015

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GIFT-I: Secondary Efficacy Results- SVR 12 Rates in ITT Subpopulations

Error bars: 95% Cl. DB, double-blind; OG LIGNENDE, open label; OBV/PTV/r, ombitasivir/partaprevir/ritonavir. Chayama et al., Abstract #G13, EASL 2015

94.6 94.9 94.2 96.1 98.1 98.5 97.4 90.5

0

20

40

60

80

100

All Primary Efficacy Population

Naïve Experienced All Naïve Experienced All

Patie

nts

with

SVR

12 (%

)

106 112

204 215

131 139

73 76

104 106

67 68

37 38

38 42

Arm A DB OBV/PTV/r

Arm B OL OBV/PTV/r

Arm C OL OBV/PTV/r

Patients without cirrhosis Patients with compensated

cirrhosis

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Does This Study Have Applicability For Countries Other Than Japan

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GT 3 Update

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Sofosbuvir Plus Peg-IFN/RBV for 12 Weeks vs Sofosbuvir/RBV for 16 or 24 Weeks in Genotype 3 HCV-Infected Patients and

Treatment-experienced Cirrhotic Patients With Genotype 2 HCV: The BOSON Study

G. Foster et al

Abstract L-05

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Study Design

•  Multicenter study, open-label, randomized (1:1:1) study at 80 sites in UK, Australia, USA, Canada, and New Zealand

•  GT 2 patients: treatment experienced (TE) with cirrhosis •  GT 3 patients: TE or treatment naïve (TN), with or without cirrhosis •  Stratification

–  Cirrhosis –  HCV Genotype –  Prior HCV treatment

•  Platelets ≥60,000 cells/mm3

SOF + RBV

12 24 Wk 0 16 28

n=196

SOF + RBV n=199

SOF + PEG/RBV n=197

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SVR12

SVR12

SVR12

Foster et al., Abstract #L-05, EASL 2015

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Overall SVR12 (GT 2 and GT 3 Combined)

SVR

12 (%

) p=0.0013 p=0.023

141/196 170/199 183/197

72

85 93

0

20

40

60

80

100

SOF + RBV 16 Weeks

SOF + RBV 24 Weeks

SOF + PEG/RBV 12 Weeks

Error bars represent 95% confidence intervals. Foster et al., Abstract #L-05, EASL 2015

141/196 170/199 183/197

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SVR12: GT 2 vs GT 3

SOF + RBV 16 weeks SOF + RBV 24 weeks SOF + PEG/RBV 12 weeks

94/112 83/100 10/11

87

71

100

84 94 93

0

20

40

60

80

100

13/15

SVR

12 (%

)

17/17 128/181

GT 2

15/16 153/182 168/181

GT 3

Error bars represent 95% confidence intervals. Foster et al., Abstract #L-05, EASL 2015

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SVR12 in GT 3 by Treatment History and Cirrhosis Status

SOF + RBV 16 weeks SOF + RBV 24 weeks SOF + PEG/RBV 12 weeks

94/112 83/100 10/11

83

57 76

47

90 82 82 77

96 91 94 86

0

20

40

60

80

100

TN no cirrhosis TN cirrhosis TE no cirrhosis TE cirrhosis

58 70

65 72

68 71

12 21

18 22

21 23

26 34

17 36

30 35

44 54

49 52

41 54

SVR

12 (%

)

Treatment Naïve Treatment Experienced

No Cirrhosis Cirrhosis No Cirrhosis Cirrhosis

Foster et al., Abstract #L-05, EASL 2015

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Daclatasvir Plus Sofosbuvir With or Without Ribavirin in Patients With HCV Genotype 3

Infection: Interim Analysis of a French Multicenter Compassionate Use Program

C. Hezode et al

Abstract LP-05

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SVR4: DCV/SOF + RBV in GT 3 Patients (12 vs 24 Weeks)

76

92 88 83

0

20

40

60

80

100

Cirrhotic Patients Non-cirrhotic Patients

SVR

4(%

)

12 Weeks 24 Weeks

22/29 52/59 11/12 5/8

EASL Recommendation: GT 3 cirrhotics should receive SOF/DCV + RBV for 24 weeks Hezode et al., Abstract #LP-05, EASL 2015

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Is SOF + PEG/RBV for 12 Weeks Standard of Care for GT 3?

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Can We Shorten Treatment Duration of SMV/SOF?

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97 95 85 77

0 20 40 60 80

100

Treatment-naïve Treatment-experienced

SVR12: SMV/SOF in GT 1 Non-cirrhotics (8 vs 12 Weeks)

Kwo et al., Abstract #LP-14, EASL 2015

Prop

ortio

n of

pa

tient

s (%

)

SMV+SOF 12 weeks SMV+SOF 8 weeks

112/ 115

88/ 103

38/ 40

40/ 52

Prop

ortio

n of

pa

tient

s (%

) 97 96 97 97 79 73 84 92

0 20 40 60 80

100

GT1a GT1a GT1a GT1b

112/ 116

92/ 116

44/ 46

36/ 49

68/ 70

56/ 67

38/ 39

36/ 39

with Q80k without Q80k

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Can We Shorten Treatment Durations to <12 Weeks By Combining Potent DAAs from Different Classes?

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C-SWIFT: Grazoprevir/Elbasvir + Sofosbuvir in Cirrhotic and Noncirrhotic Treatment-naive

Patients With Hepatitis C Virus GT 1 Infection, for Durations of 4, 6 or 8 Weeks

and GT 3 Infection for Durations of 8 or 12 Weeks

F. Poordad et al

Abstract O006

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87 80 94

0

20

40

60

80

100

1 2 3 4

SVR

12 (%

, 95%

CI)

SVR12 in GT 1 Treatment-naïve Patients

10 30*

17 18

16 20

26 30

4 weeks 6 weeks 6 weeks 8 weeks

Non-cirrhotic Cirrhotic

*Excluded patients who discontinued due to reasons other than virologic failure † One of the 3 patients who discontinued had HCV G2 at discontinuation

Breakthrough 0 0 0 0 Relapse 20 4 4 1 Excluded* 1 0 0 3†

Poordad et al., Abstract #O006, EASL 2015

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93 100 91

0

20

40

60

80

100

8 weeks 12 weeks 12 weeks

HC

V R

NA

<15

IU/m

L (%

, 95%

CI)

14 15

Non- cirrhotic

Cirrhotic

10 11

14 14

mITT analysis excluded patients who discontinued early due to reasons other than virologic failure

SVR12 in GT 3 Treatment-naïve Patients

Poordad et al., Abstract #O006, EASL 2015

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Are There Long-Term Consequences of Treating for Too Short?

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Retreatment of Patients Who Failed 8 or 12 Weeks of Ledipasvir/Sofosbuvir-Based

Regimens With Ledipasvir/Sofosbuvir for 24 Weeks

E. Lawitz et al

Abstract O005

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SVR12 by Subgroup

68 80

100 74

46 60

0

20

40

60

80

100

No Yes 8 wks 12 wks No Yes

15/22 14/19 24/30 5/11 11/11 18/30

Cirrhosis Prior Treatment Duration

Baseline NS5A RAVs

All 11 patients without NS5A RAVs received 8 weeks of prior treatment

SVR

12 (%

)

No Yes

•  Overall SVR12=71% (29/41)

Lawitz et al., Abstract #O005, EASL 2015

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How Do We Best Manage Patients with NS5A RAVs?

Should All Patients Have Baseline

RAV Testing?

How Long Before Retreating a Patient with RAVs?

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Advanced Cirrhosis/Post-OLT

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Regimens With New Data

•  SOLAR 2: SOF/LDV/RBV (G02; Manns, et al)

–  12 vs 24 week treatment

–  GT 1 and GT 4 CPT B&C

–  SVR12: 88% (57/65) (12 wk arm) vs 89% (54/61) (24 wk arm)

•  UK EAP: SOF + LDV or DCV + RBV (O002; Foster, et al)

–  12 week treatment

–  GT 1 and GT 3 CP-B and C patients (Mean MELD=11.9)

–  Virologically effective with >40% showing improvement in liver function

–  For patients <65 years if albumin is >35 g/L, improvement in liver function is more likely than harm

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Regimens With New Data

•  ALLY 1: DCV/SOF/RBV (L-08; Poordad, et al)

–  12 week treatment

–  Any genotype enrolled but predominantly GT 1

–  Advanced cirrhosis (CPT A, B and C patients) and post-OLT

–  SVR12: CPT A=92% (11/12), CPT B=94% (30/32), CPT C=56% (9/16) and post-OLT=94% (50/53)

•  C-SALT: GZR/EBR (O008; Jacobson, et al)

–  12 week treatment

–  GT 1 CPT B patients (Mean MELD=9.9)

–  SVR12: 90% (27/30)

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Advantages vs Disadvantages of Treating Advanced Cirrhosis vs Post-OLT

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“EASL Recommendations on Treatment of Hepatitis C 2015” issued this week (J Hep).

Is there any impact on current practice?

Drug:drug interaction concerns?

Community/primary care vs specialized care setting?

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Best of HCV from EASL 2015

This activity is supported by educational grants from AbbVie, Bristol-Myers Squibb, and Gilead Sciences.